XRP Custom Order Form

PLEASE PRINT THIS ORDER FORM AND EMAIL IT BACK TO US FILLED OUT WITH ALL INFORMATION NEEDED

PRICE WILL BE DETERMINED AFTER OUR REVIEW OF ORDER FORM

EMAIL ORDER FORM TO:  ROCKYB@PMRSPEEDSHOP.COM

• Customer Information
  • Name
  • Company
  • Address
  • City / State / Zip
  • Phone
  • Email
  • PO Number
  • Date
• Hose Assembly Information
  • □ HS79
  • □ ProPlus Xtra Monofilament
  • □ ProPlus Aramid Fiber
  • Size
  • Style (Straight, 45°, 60°, 90°, 120°, 150°, 180°)
  • Size
  • Style (Straight, 45°, 60°, 90°, 120°, 150°, 180°)
  • □ Nickel
  • □ Black
  • □ Gold
  • Quantity
  • Hose Size (6, 8, 10, 12, 16)
  • Hose Type
  • End A
  • End B
  • Collar Color
  • Clocking/Orientation
  • Special Instructions
• Measuring Diagram
  • Measure to the centerline of any turned fitting (45°, 60°, 90°, 120°, 150°, 180°). When a straight fitting is used on one or both ends, measure to the end of the straight fitting